DRAFT AFFIDAVIT # 2 (To be used to prove disabled adult ...



AFFIDAVIT

IN THE MATTER OF THE APPLICATION OF

________________

SS# ____________

FOR SUPPLEMENTAL SECURITY INCOME BENEFITS

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STATE OF ___________:

COUNTY OF ______ : SS

CITY OF ___________ :

I, (NON DISABLED ADULT) being duly sworn, deposes and says:

1. I reside at ____________________________________.

2. I provide room and lodging for my adult disabled (RELATIONSHIP), (NAME OF DISABLED ADULT), at the above address each month for a flat fee pursuant to an oral business agreement.

3. I charge (NAME OF DISABLED ADULT) $_____ per month for room and lodging pursuant to that oral agreement.

4. I would charge the same amount, $_____ per month for any nonrelatives who I took in as a roomer-lodgers under a similar business arrangement.

5. (NAME OF DISABLED ADULT) has no equity or property interest in my home.

6. (NAME OF DISABLED ADULT) does not share in the insurance, maintenance, repair, furnishing, decorating, utilities, or any other operational cost of my home.

7. (NAME OF DISABLED ADULT) does not participate in any decisions regarding home repairs, improvements, or other aspects of daily activities.

8. We do not "pool" our funds for any household expenses.

9. (NAME OF DISABLED ADULT) does not contribute to, nor does his name appear on any bills as a responsible party for my actual expenses of operating the house on a per expense or pro-rata basis because he is a roomer-lodger in my home.

10. I understand that it is the policy of the Social Security Administration that when a recipient of Supplemental Security Income benefits (SSI) resides with others, household expenses must be apportioned and that a recipient must pay a pro-rata share of these costs in order to receive the regulated amount of SSI benefits.

11. However, as of (DATE ARRANGEMENT BEGAN), following our agreement, (NAME OF DISABLED ADULT) is now paying a flat fee of $______ a month for room and lodgings. Since I, myself, am not in receipt of any Social Security benefits, I am unwilling to apportion my household expenses according to Social Security policy.

12. If (DISABLED ADULT) is unable to pay the flat fee for rent for his room and lodging, I will make him leave.

13. I do not contribute in any ways to the needs of (DISABLED ADULT).

_____________________________

Affiant

Sworn to before me this ____

day of _________, 20__.

______________________________

Notary Public

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